Longitudinal Comparison of PNES spell and ASM reduction in PNES Patients with and without Epilepsy Discharged from an Epilepsy Monitoring Unit

OBJECTIVE

To examine trends of Antiseizure Medication (ASM) reduction and discontinuation, as well as Psychogenic Non-Epileptic Seizure (PNES) spell reduction and resolution in patients with PNES, with and without comorbid epileptic seizures (ES).

METHODS

A retrospective analysis was conducted on data from 145 patients with PNES, including 109 with PNES alone and 36 with PNES plus comorbid epilepsy. Patients were admitted to the Epilepsy Monitoring Unit (EMU) between May 2000 and April 2008, with follow-up clinical data collected until September 2015. Clinical records were thoroughly examined, encompassing the period preceding the PNES diagnosis until either loss to follow-up or September 2015. A subsequent chart review was conducted by two neurologists, covering the period following the diagnosis of PNES until either loss to follow-up or September 2015, which ever came first.

RESULTS

Patients with PNES alone had higher rates of ASM reduction for all variables of ASM reduction measured compared to those with comorbid epilepsy (all at p < 001). Among patients with PNES alone, reductions in ASMs were observed after EMU discharge, but an uptick and plateau were seen in later follow-up years (100% of patients free of ASMs at years 2-3, 20% on at least one ASM by year 7). This pattern differs greatly in PNES + ES patients, in which the only time point at which any patient was able to discontinue all ASMs was at EMU discharge (4.5% of patients), with all patients taking at least one ASM for every other follow-up time point. Reductions in PNES spell frequency did not differ significantly between the two groups (for example PNES spells reduced at final FU 47.2% vs 42.9%, p = 0.65). In both groups, despite an initial drop in variables of PNES spell reduction and resolution in the early years post discharge, there is an eventual rebound and plateau (for example in PNES only patients, 33.9% of patients having no resolution in 1st year FU, which rises to 78% at years 4-5, and plateus around 52.8% at more than 7 years follow-up.) SIGNIFICANCE: This study contributes to the growing body of research focused on improving the current approach to management and prognostic outlook of PNES. Although PNES only patients had higher rates of ASM reduction, the uptick and plateau observed in later years highlights the challenges in managing PNES. Similarly, the continued persistence and rebound of PNES spells underline the continued poor prognostic outcomes associated with this condition.

Obsessive-Compulsive Disorder as an Epiphenomenon of Comorbid Bipolar Disorder? An Updated Systematic Review

BACKGROUND

Bipolar disorder (BD) and obsessive-compulsive disorder (OCD) comorbidity is an emerging condition in psychiatry, with relevant nosological, clinical, and therapeutic implications.

METHODS

We updated our previous systematic review on epidemiology and standard diagnostic validators (including phenomenology, course of illness, heredity, biological markers, and treatment response) of BD-OCD. Relevant papers published until (and including) 15 October 2023 were identified by searching the electronic databases MEDLINE, Embase, PsychINFO, and Cochrane Library, according to the PRISMA statement (PROSPERO registration number, CRD42021267685).

RESULTS

We identified 38 new articles, which added to the previous 64 and raised the total to 102. The lifetime comorbidity prevalence ranged from 0.26 to 27.8% for BD and from 0.3 to 53.3% for OCD. The onset of the two disorders appears to be often overlapping, although the appearance of the primary disorder may influence the outcome. Compared to a single diagnosis, BD-OCD exhibited a distinct pattern of OC symptoms typically following an episodic course, occurring in up to 75% of cases (vs. 3%). Notably, these OC symptoms tended to worsen during depressive episodes (78%) and improve during manic or hypomanic episodes (64%). Similarly, a BD course appears to be chronic in individuals with BD-OCD in comparison to patients without. Additionally, individuals with BD-OCD comorbidity experienced more depressive episodes (mean of 8.9 ± 4.2) compared to those without comorbidity (mean of 4.1 ± 2.7).

CONCLUSIONS

We found a greater likelihood of antidepressant-induced manic/hypomanic episodes (60% vs. 4.1%), and mood stabilizers with antipsychotic add-ons emerging as a preferred treatment. In line with our previous work, BD-OCD comorbidity encompasses a condition of greater nosological and clinical complexity than individual disorders.

Individual variation in brain network topology is linked to course of illness in major depressive disorder

Major depressive disorder (MDD) is a chronic and highly recurrent disorder. The functional connectivity in depression is affected by the cumulative effect of course of illness. However, previous neuroimaging studies on abnormal functional connection have not mainly focused on the disease duration, which is seen as a secondary factor. Here, we used a data-driven analysis (multivariate distance matrix regression) to examine the relationship between the course of illness and resting-state functional dysconnectivity in MDD. This method identified a region in the anterior cingulate cortex, which is most linked to course of illness. Specifically, follow-up seed analyses show this phenomenon resulted from the individual differences in the topological distribution of three networks. In individuals with short-duration MDD, the connection to the default mode network was strong. By contrast, individuals with long-duration MDD showed hyperconnectivity to the ventral attention network and the frontoparietal network. These results emphasized the centrality of the anterior cingulate cortex in the pathophysiology of the increased course of illness and implied critical links between network topography and pathological duration. Thus, dissociable patterns of connectivity of the anterior cingulate cortex is an important dimension feature of the disease process of depression.

White matter fiber microstructure is associated with prior hospitalizations rather than acute symptomatology in major depressive disorder

BACKGROUND

Eighty percent of all patients suffering from major depressive disorder (MDD) relapse at least once in their lifetime. Thus, understanding the neurobiological underpinnings of the course of MDD is of utmost importance. A detrimental course of illness in MDD was most consistently associated with superior longitudinal fasciculus (SLF) fiber integrity. As similar associations were, however, found between SLF fiber integrity and acute symptomatology, this study attempts to disentangle associations attributed to current depression from long-term course of illness.

METHODS

A total of 531 patients suffering from acute (N = 250) or remitted (N = 281) MDD from the FOR2107-cohort were analyzed in this cross-sectional study using tract-based spatial statistics for diffusion tensor imaging. First, the effects of disease state (acute v. remitted), current symptom severity (BDI-score) and course of illness (number of hospitalizations) on fractional anisotropy (FA), mean diffusivity (MD), radial diffusivity (RD), and axial diffusivity were analyzed separately. Second, disease state and BDI-scores were analyzed in conjunction with the number of hospitalizations to disentangle their effects.

RESULTS

Disease state (p_FWE < 0.042) and number of hospitalizations (p_FWE< 0.032) were associated with decreased FA and increased MD and RD in the bilateral SLF. A trend was found for the BDI-score (p_FWE > 0.067). When analyzed simultaneously only the effect of course of illness remained significant (p_FWE < 0.040) mapping to the right SLF.

CONCLUSIONS

Decreased FA and increased MD and RD values in the SLF are associated with more hospitalizations when controlling for current psychopathology. SLF fiber integrity could reflect cumulative illness burden at a neurobiological level and should be targeted in future longitudinal analyses.

Perceived Course of Illness on the Desire for Social Distance From People Suffering From Symptoms of Schizophrenia in India

BACKGROUND

Stigmatization of people with schizophrenia remains a highly relevant topic worldwide, particularly in low- and middle-income countries like India. It is crucial to identify the determinants of the desire for social distance as a proxy for discriminatory behavior in a socio-cultural context to indicate ways to reduce stigma. This study aims to explore whether the public perception of the perceived course of an illness concerning people with symptoms of schizophrenia has an impact on the desire for social distance.

SUBJECTS AND METHODS

Data collection took place in five cities in India. The sample (N = 447) was stratified for gender, age, and religion. Desire for social distance was sampled based on a self-reported questionnaire using unlabelled vignettes for schizophrenia. First, factor analysis was conducted to identify the main factors underlying the perception of the perceived course of the illness. Subsequently, a regression analysis was conducted to examine the impact of the perception of those prognostic factors on the desire for social distance.

RESULTS

Factor analysis revealed two independent factors of the perceived course of an illness: (1) life-long dependency on others and loss of social integration and functioning and (2) positive expectations toward treatment outcome. This second factor was significantly associated with a less desire for social distance toward persons with schizophrenia.

CONCLUSION

The desire for social distance toward people with schizophrenia reduces with the expectation of positive treatment outcomes which underlines the need to raise public mental health awareness and provide psychoeducation for affected people and their family members in India. Help-seeking behaviors can be promoted by directing those needing treatment toward locally available, affordable and credible community-based services rather than facility-based care. Strikingly, lifelong dependency and the inability to socially integrate do not increase the desire for social distance, reflecting the Indian nation's socio-relational values and insufficiency of public mental health services. This indicates the suitability of systemic therapy approaches in public mental healthcare services to support the family's involvement and family-based interventions in caregiving for mentally ill people across the lifespan.

Impact of clozapine on disability and course of illness in patients with schizophrenia: A study from North India

AIM

The aim of this study was to evaluate the impact of long-term use of clozapine on disability and course of illness among patients with treatment-resistant schizophrenia.

MATERIALS AND METHODS

102 participants who have been receiving clozapine for a mean duration of 5 years were evaluated on Positive and Negative Syndrome Scale (PANSS) rating, Clinical Global Impression (CGI) severity rating, and Indian Disability Evaluation and Assessment Scale (IDEAS) and the scores were compared with the scores on the same scales at the time of starting clozapine.

RESULTS

There was a significant reduction in both CGI-severity scores and scores in all the four domains of IDEAS, alongside a significant reduction on all three subscales of PANSS with clozapine treatment. The CGI global improvement subscale was rated as very much improved for 80 patients. In terms of course of symptoms, at 6 months of clozapine use, three-fourth of the patients were rated as having partial recovery with no relapse of symptoms, but with passage of time, the proportion of patients in the category of "complete recovery" was found to be increasing. Higher CGI severity at the follow-up, lower CGI global improvement, and poorer efficacy index were associated with higher disability at the follow-up.

CONCLUSIONS

The present study suggests that clozapine has a significant beneficial impact on disability and course of illness among patients with treatment-resistant schizophrenia.

Smartphone-Based Self-Reports of Depressive Symptoms Using the Remote Monitoring Application in Psychiatry (ReMAP): Interformat Validation Study

BACKGROUND

Smartphone-based symptom monitoring has gained increased attention in psychiatric research as a cost-efficient tool for prospective and ecologically valid assessments based on participants' self-reports. However, a meaningful interpretation of smartphone-based assessments requires knowledge about their psychometric properties, especially their validity.

OBJECTIVE

The goal of this study is to systematically investigate the validity of smartphone-administered assessments of self-reported affective symptoms using the Remote Monitoring Application in Psychiatry (ReMAP).

METHODS

The ReMAP app was distributed to 173 adult participants of ongoing, longitudinal psychiatric phenotyping studies, including healthy control participants, as well as patients with affective disorders and anxiety disorders; the mean age of the sample was 30.14 years (SD 11.92). The Beck Depression Inventory (BDI) and single-item mood and sleep information were assessed via the ReMAP app and validated with non-smartphone-based BDI scores and clinician-rated depression severity using the Hamilton Depression Rating Scale (HDRS).

RESULTS

We found overall high comparability between smartphone-based and non-smartphone-based BDI scores (intraclass correlation coefficient=0.921; P<.001). Smartphone-based BDI scores further correlated with non-smartphone-based HDRS ratings of depression severity in a subsample (r=0.783; P<.001; n=51). Higher agreement between smartphone-based and non-smartphone-based assessments was found among affective disorder patients as compared to healthy controls and anxiety disorder patients. Highly comparable agreement between delivery formats was found across age and gender groups. Similarly, smartphone-based single-item self-ratings of mood correlated with BDI sum scores (r=-0.538; P<.001; n=168), while smartphone-based single-item sleep duration correlated with the sleep item of the BDI (r=-0.310; P<.001; n=166).

CONCLUSIONS

These findings demonstrate that smartphone-based monitoring of depressive symptoms via the ReMAP app provides valid assessments of depressive symptomatology and, therefore, represents a useful tool for prospective digital phenotyping in affective disorder patients in clinical and research applications.

The longitudinal course of schizophrenia: testosterone and progression of the negative symptoms

Background: The longitudinal course of schizophrenia shows a high level of heterogeneity with testosterone as a possible factor in the variety of clinical outcomes.Aim: Evaluation of the course of schizophrenia in male patients over an eight-year period and of the possible testosterone effects on changes in clinical features.Subjects and methods: The initial study population consisted of 120 male schizophrenic patients (aged 18-40) hospitalized in the University Psychiatric Hospital Vrapce in 2009. Patients were classified into nonaggressive (control, n = 60) and aggressive (n = 60) groups. In 2017, we reassessed 85 patients (67,5%) from the initial sample. Symptoms of schizophrenia were determined using the Positive and Negative Syndrome Scale (PANSS) and compared with the total serum testosterone level taken at the inclusion in the study. The distribution of values for individual variables was determined using the Smirnov-Kolmogorov test; for all further analyses, the appropriate non-parametric test was used.Results: The control group showed a statistically significant negative correlation between testosterone and negative PANSS. The initial PANSS scores, compared to those at the follow-up, showed a statistically significant reduction in positive and general symptoms in all groups, with the greatest reduction in the control group.Conclusion: We found a reduction in positive and general symptoms of schizophrenia among all patients and no changes in negative symptoms. Inverse correlation between testosterone and negative symptoms was found only in the control group, but there was no testosterone influence on the progression of any PANSS subscales.

Chronic obsessive-compulsive disorder: prognostic factors

BACKGROUND

The course of illness in obsessive-compulsive disorder (OCD) varies significantly between patients. Little is known about factors predicting a chronic course of illness. The aim of this study is to identify factors involved in inducing and in maintaining chronicity in OCD.

METHODS

The present study is embedded within the Netherlands Obsessive Compulsive Disorder Association (NOCDA) study, an ongoing multicenter naturalistic cohort study designed to identify predictors of long-term course and outcome in OCD. For this study, 270 subjects with a current diagnosis of OCD were included. Chronicity status at 2-year follow-up was regressed on a selection of baseline predictors related to OCD, to comorbidity and to stress and support.

RESULTS

Psychotrauma [odds ratio (OR) 1.98, confidence interval (CI) 1.22-3.22, p = 0.006], recent negative life events (OR 1.42, CI 1.01-2.01, p = 0.043), and presence of a partner (OR 0.28, CI 0.09-0.85, p = 0.025) influenced the risk of becoming chronic. Longer illness duration (OR 1.46, CI 1.08-1.96, p = 0.013) and higher illness severity (OR 1.09, CI 1.03-1.16, p = 0.003) increased the risk of remaining chronic.

CONCLUSIONS

External influences increase the risk of becoming chronic, whereas the factors involved in maintaining chronicity are illness-related. As the latter are potentially difficult to modify, treatment should be devoted to prevent chronicity from occurring in the first place. Therapeutic strategies aimed at alleviating stress and at boosting social support might aid in achieving this goal.

Sex similarities and differences in risk factors for recurrence of major depression

BACKGROUND

Major depression (MD) occurs about twice as often in women as in men, but it is unclear whether sex differences subsist after disease onset. This study aims to elucidate potential sex differences in rates and risk factors for MD recurrence, in order to improve prediction of course of illness and understanding of its underlying mechanisms.

METHODS

We used prospective data from a general population sample (n = 653) that experienced a recent episode of MD. A diverse set of potential risk factors for recurrence of MD was analyzed using Cox models subject to elastic net regularization for males and females separately. Accuracy of the prediction models was tested in same-sex and opposite-sex test data. Additionally, interactions between sex and each of the risk factors were investigated to identify potential sex differences.

RESULTS

Recurrence rates and the impact of most risk factors were similar for men and women. For both sexes, prediction models were highly multifactorial including risk factors such as comorbid anxiety, early traumas, and family history. Some subtle sex differences were detected: for men, prediction models included more risk factors concerning characteristics of the depressive episode and family history of MD and generalized anxiety, whereas for women, models included more risk factors concerning early and recent adverse life events and socioeconomic problems.

CONCLUSIONS

No prominent sex differences in risk factors for recurrence of MD were found, potentially indicating similar disease maintaining mechanisms for both sexes. Course of MD is a multifactorial phenomenon for both males and females.

Clinical and functional outcomes of cannabis use among individuals with anxiety disorders: A 3-year population-based longitudinal study

BACKGROUND

Cannabis use has been reported to negatively affect the course and outcome of various psychiatric disorders, yet little is known on its effect on rates of remission from anxiety disorders and associated clinical and functional outcomes.

METHODS

In this study, data were drawn from Waves 1 and 2 of the National Epidemiologic survey on Alcohol and Related Conditions, focusing on individuals who qualified for a diagnosis of any anxiety disorder (social anxiety, panic disorder, generalized anxiety disorder, and specific phobias) at Wave 1 (N = 3,723). Cannabis users and individuals with cannabis use disorders (CUDs) throughout a 4-year period were compared to nonusers in rates of remission, suicidality, general functioning, and quality of life at Wave 2, while controlling for baseline confounders.

RESULTS

Although rates of remission decreased with level of cannabis use, this was not maintained in adjusted models. Aside from specific outcomes (individuals with CUDs were significantly more prone to report breaking up from a romantic relationship; adjusted odds ratio [AOR] = 3.85, 95% confidence interval [CI] = 1.66-8.97) and repeatedly quitting school (AOR = 6.02, 95% CI = 2.65-13.66)), following adjustment no additional differences were found in outcome measures.

CONCLUSIONS

These findings add to previous reports suggesting that poorer outcome of anxiety disorders among cannabis users may be attributed mainly to differences in baseline factors and not cannabis use.

Recovery in patients with major depressive disorder (MDD): results of a 6-month, multinational, observational study

Not all individuals treated for major depressive disorder (MDD) achieve recovery. This observational study examined the recovery rates in MDD patients and the patient characteristics associated with achieving recovery in a naturalistic clinical setting. Recovery was defined as having both clinical and functional remission. Data for this post hoc analysis were taken from a 24-week prospective, observational study that involved 1,549 MDD patients. Clinical remission was assessed using the 16-item Quick Inventory of Depressive Symptomatology Self-Report and functional remission through the Sheehan Disability Scale and no days of reduced productivity in the previous week. Generalized estimating equation regression models were used to examine the baseline factors associated with recovery during follow-up. Clinical and functional remission was achieved in 70.6% and 56.1% of the MDD patients, respectively. MDD patients who achieved recovery (52.1%) were significantly less likely to have impaired levels of functioning, concurrent medical or psychiatric conditions, low levels of education, or nonadherence to therapy at follow-up. The level of functioning during the index episode seems to be a better predictor of recovery than symptom severity. Therefore, the level of functioning should be considered while determining recovery from depression.

Rates and predictors of remission, recurrence and conversion to bipolar disorder after the first lifetime episode of depression--a prospective 5-year follow-up study

BACKGROUND

In depression, non-remission, recurrence of depressive episodes after remission and conversion to bipolar disorder are crucial determinants of poor outcome. The present study aimed to determine the cumulative incidences and clinical predictors of these long-term outcomes after the first lifetime episode of depression.

METHOD

A total of 301 in- or out-patients aged 18-70 years with a validated diagnosis of a single depressive episode were assessed from 2005 to 2007. At 5 years of follow-up, 262 patients were reassessed by means of the life chart method and diagnostic interviews from 2011 to 2013. Cumulative incidences and the influence of clinical variables on the rates of remission, recurrence and conversion to bipolar disorder, respectively, were estimated by survival analysis techniques.

RESULTS

Within 5 years, 83.3% obtained remission, 31.5% experienced recurrence of depression and 8.6% converted to bipolar disorder (6.3% within the first 2 years). Non-remission increased with younger age, co-morbid anxiety and suicidal ideations. Recurrence increased with severity and treatment resistance of the first depression, and conversion to bipolar disorder with treatment resistance, a family history of affective disorder and co-morbid alcohol or drug abuse.

CONCLUSIONS

The identified clinical characteristics of the first lifetime episode of depression should guide patients and clinicians for long-term individualized tailored treatment.

Combined treatment: impact of optimal psychotherapy and medication in bipolar disorder

OBJECTIVES

The current study investigated the longitudinal course of symptoms in bipolar disorder among individuals receiving optimal treatment combining pharmacotherapy and psychotherapy, as well as predictors of the course of illness.

METHODS

A total of 160 participants with bipolar disorder (bipolar I disorder: n = 115; bipolar II disorder: n = 45) received regular pharmacological treatment, complemented by a manualized, evidence-based psychosocial treatment - that is, cognitive behavioral therapy or psychoeducation. Participants were assessed at baseline and prospectively for 72 weeks using the Longitudinal Interval Follow-up Evaluation (LIFE) scale scores for mania/hypomania and depression, as well as comparison measures (clinicaltrials.gov identifier: NCT00188838).

RESULTS

Over a 72-week period, patients spent a clear majority (about 65%) of time euthymic. Symptoms were experienced more than 50% of the time by only a quarter of the sample. Depressive symptoms strongly dominated over (hypo)manic symptoms, while subsyndromal symptoms were more common than full diagnosable episodes for both polarities. Mixed symptoms were rare, but present for a minority of participants. Individuals experienced approximately six significant mood changes per year, with a full relapse on average every 7.5 months. Participants who had fewer depressive symptoms at intake, a later age at onset, and no history of psychotic symptoms spent more weeks well over the course of the study.

CONCLUSIONS

Combined pharmacological and adjunctive psychosocial treatments appeared to provide an improved course of illness compared to the results of previous studies. Efforts to further improve the course of illness beyond that provided by current optimal treatment regimens will require a substantial focus on both subsyndromal and syndromal depressive symptoms.

The Effect of Violence on the Diagnoses and the Course of Illness Among Female Psychiatric Inpatients

INTRODUCTION

The aim of the study was to determine the rate of exposure to domestic violence among female inpatients at any period of their lives; to investigate the effect of different forms of violence on the diagnoses and the course of the illness.

METHOD

The study was conducted on 102 female inpatients treated at Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery. The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) was administered and socio-demographic and clinical data was collected. A form designed for the assessment of violence was used to evaluate domestic violence.

RESULTS

Ninety patients reported that they had been subjected to some kind of violence at some period of their lives. The parents or husbands were the most frequently reported persecutors. Seventy-three patients reported that they had been subjected to violence before the onset of their illness. Seventy-one had been subjected to physical, 79 to verbal, 42 to sexual, 52 to economic violence, and 49 to constraints on social relationship formation. Comorbid diagnosis of post traumatic stress disorder (PTSD) was related to all types of violence. The rate of suicide attempt was found to be significantly related to verbal-emotional violence. Only 12 patients had previously reported being subjected to domestic violence to their psychiatrist.

CONCLUSION

Domestic violence, an often overlooked phenomenon, is prevalent among women with psychiatric disorders. Subjection to domestic violence is found to be correlated with PTSD and suicidal attempt.

Anxiety interacts with expressed emotion criticism in the prediction of psychotic symptom exacerbation

Psychotic symptoms are exacerbated by social stressors in schizophrenia and schizoaffective disorder patients as a group. More specifically, critical attitudes toward patients on the part of family members and others have been associated with a higher risk of relapse in the patients. Some patients appear to be especially vulnerable in this regard. One variable that could affect the degree of sensitivity to a social stressor such as criticism is the individual's level of anxiety. The present longitudinal study assessed 27 relatively stable outpatients with schizophrenia or schizoaffective disorder and the single "most influential other" (MIO) person for each patient. As hypothesized, (1) patients with high critical MIOs showed increases in psychotic symptoms over time, compared with patients with low critical MIOs; (2) patients high in anxiety at the baseline assessment showed increases in psychotic symptoms at follow-up, compared with patients low in anxiety, and (3) patients with high levels of anxiety at baseline and high critical MIOs showed the greatest exacerbation of psychotic symptoms over time. Objectively measured levels of criticism were more predictive than patient-rated levels of criticism.

Childhood predictors of adult attention-deficit/hyperactivity disorder: results from the World Health Organization World Mental Health Survey Initiative

BACKGROUND

Although it is known that childhood attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood, childhood predictors of this persistence have not been widely studied.

METHODS

Childhood history of ADHD and adult ADHD were assessed in 10 countries in the World Health Organization World Mental Health Surveys. Logistic regression analysis was used to study associations of retrospectively reported childhood risk factors with adult persistence among the 629 adult respondents with childhood ADHD. Risk factors included age; sex; childhood ADHD symptom profiles, severity, and treatment; comorbid child/adolescent DSM-IV disorders; childhood family adversities; and child/adolescent exposure to traumatic events.

RESULTS

An average of 50% of children with ADHD (range: 32.8%-84.1% across countries) continued to meet DSM-IV criteria for ADHD as adults. Persistence was strongly related to childhood ADHD symptom profile (highest persistence associated with the attentional plus impulsive-hyperactive type, odds ratio [OR]=12.4, compared with the lowest associated with the impulsive-hyperactive type), symptom severity (OR=2.0), comorbid major depressive disorder (MDD; OR=2.2), high comorbidity (>or=3 child/adolescent disorders in addition to ADHD; OR=1.7), paternal (but not maternal) anxiety mood disorder (OR=2.4), and parental antisocial personality disorder (OR=2.2). A multivariate risk profile of these variables significantly predicts persistence of ADHD into adulthood (area under the receiving operator characteristic curve=.76).

CONCLUSIONS

A substantial proportion of children with ADHD continue to meet full criteria for ADHD as adults. A multivariate risk index comprising variables that can be assessed in adolescence predicts persistence with good accuracy.

Scientific and consumer models of recovery in schizophrenia: concordance, contrasts, and implications

Schizophrenia has traditionally been viewed as a chronic condition with a very pessimistic outlook, but that assumption may not be valid. There has been a growing consumer movement among people with schizophrenia that has challenged both the traditional perspective on the course of illness and the associated assumptions about the possibility of people with the illness living a productive and satisfying life. This new conception of the illness is supported by long-term studies that suggest that as much as 50% of people with the illness have good outcomes. There has also been a change in political and public health perspectives of the illness, stimulated in part by the President's New Freedom Commission on Mental Health. The purpose of this article is to provide an overview of some key themes about the recovery concept, as applied to schizophrenia. The article will address 3 questions: (1) What is recovery? (2) Is recovery possible? and (3) What are the implications of a recovery model for a scientific approach to treatment (ie, the use of evidence-based practices)? Scientific and consumer models of recovery are described, and commonalities and differences are discussed. Priorities for future research are suggested.

Commentary on N. Ghaemi's "Hippocratic Psychopharmacology of Bipolar Disorder" Treating Bipolar Disorder: For the Patient or Against the Illness?

OBJECTIVE

This is a commentary on Hippocratic Psychopharmacology in Bipolar Disorder, an article by S. Nasir Ghaemi in this issue of Psychiatry 2006.

DESIGN

Based on Dr. Ghaemi's article and relevant literature, I discuss implications of Hippocratic treatment, i.e., the principle of treating an underlying illness using methods that enhance the patient's adaptive responses, rather than using symptomatic treatments.

RESULTS AND DISCUSSION

Key points include 1) the course of illness, as heterogeneous as it is, seems to have episodic-stable and inherently unstable forms; 2) course of illness interacts with episode characteristics, with mixed or polyphasic episodes associated with an unstable and complicated course of illness; 3) consequences in terms of treatment response, with lithium being more effective in treating the episodic-stable than the unstable form of the illness; and 4) the fact that, in determining treatment response, course of illness trumps episode characteristics. The goal of Hippocratic/Oslerian medicine, curative treatment aimed at underlying mechanisms of disease, is the aim of treatment, but is still elusive.